Healing Center

Doctors have written about carpal tunnel syndrome (CTS) for more than 100 years, but it took the emergence of computer keyboards for the condition to achieve national prominence. In fact, any activity that constantly strains the wrist, from guitar playing to rowing, from assembly line work to knitting, can bring it on. Sometimes, however, carpal tunnel syndrome can begin without any apparent cause at all. Carpal tunnel syndrome usually starts as repeated local irritations or different medical conditions that lead to swelling of the tendons and ligaments in the wrist. This then compresses the median nerve, which passes through a "tunnel" from the forearm to the hand. The combination of the inflamed tendons and the squeezed median nerve are responsible for the pain, tingling, numbness and weakness of the thumb and index and middle fingers characteristic of CTS. In addition, any of the following have been associated with this painful condition: an underactive thyroid, diabetes, rheumatoid arthritis, obesity, pregnancy, premenstrual syndrome (PMS), birth control pills, and menopause. Although conventional medicine can be very helpful, I believe one of its options, namely surgery, should be the last resort. As many physicians are unaware of alternative therapies, let's see if our WholeHealthMD suggestions can help keep you out of the operating room. No guarantees, of course, but nothing ventured . . .

Foods high in vitamin B6 may reduce discomfort from swelling that affects the hands and wrists of people who suffer from carpal tunnel syndrome. Inflammation resulting from carpal tunnel syndrome may be reduced by bromelain, an enzyme found in pineapple. Also, foods that are high in riboflavin may be beneficial for circulation.

What is Carpal Tunnel Syndrome?
Carpal tunnel syndrome is a painful disorder of the wrist and hand that affects some 5 million Americans. Carpal tunnel refers to a passageway in the wrist, composed of bones and ligaments, through which a major nerve system passes from the forearm into the hand.

For a variety of reasons--repetitive strain, arthritis, bone dislocation or fracture, fluid retention, or a variety of systemic changes affecting the entire body, such as diabetes--the carpal tunnel can become narrowed. When this occurs, the median nerve, which controls feeling and movement in the hand, is compressed by surrounding tissue or excess fluid. As the nerve is constricted, it causes numbness, weakness, or pain. Often affecting the dominant hand (though possible in both hands), these symptoms may appear suddenly or gradually, and may last for only a few days at a time or persist for several months.

Women are far more susceptible than men are to carpal tunnel syndrome, in large part because more women perform the types of hand-intensive tasks (especially typing on computer keyboards) that put them at risk. The condition is also common among overweight women between ages 30 and 60 who have been pregnant. The sooner carpal tunnel syndrome is diagnosed, the easier it is to treat--and the better the prognosis. Left untreated, however, the inflammation can lead to scarring in the area, resulting in a weakened grip and severe chronic pain in the forearm or shoulder.

What Causes Carpal Tunnel Syndrome?
While carpal tunnel syndrome is often considered a modern-day ailment, a stress injury caused by too many tense hours spent at a keyboard. In fact, it was first diagnosed in the 1880s, long before computers reigned, and its rise has been attributed to several factors, including:

Activities that require prolonged repeated movements of the hands or fingers and flexing of the wrist. This encompasses not only typing, but also knitting, sewing, drilling, carpentry, assembly-line work, playing a musical instrument and certain sports, such as tennis, squash, canoeing, and the use of rowing machines or other exercise equipment.

Injury or trauma that causes nerve damage in the wrist.

Hormonal changes due to pregnancy, birth control pills or menopause.

Diseases such as diabetes, hypothyroidism, rheumatoid arthritis, or Raynaud's disease.

Being born into a family that has a predisposing anatomy, i.e. a narrow carpal tunnel

Poor posture not only of the arm and wrist, but also of the neck and upper back where the nerve originates

Nutritional deficencies that make the tissue more succeptible to developing inflammation

It appears that development of CTS is acombination of both mechanical stress (repetitive use, predisposing anatomy, or bad posture) and localized chemical changes that happen in response to this stress. Research has shown people who have CTS, have a variety of specific pro-inflammatory chemicals in their carpal tunnel tissue. These chemicals lead to greater swelling and possible scarring.

Whether choosing conventional or alternative treatments, the best results are obtained when treatment is started early. If you begin treatment, soon after the symptoms appear, there is less risk of developing tissue scarring and nerve damage. Picking a treatment for CTS depends on the cause and severity of symptoms. If it is caused by repetitive mechanical stress, the treatment involves alleviating the stress through splinting, avoiding aggravating activities, and prescribing medications to decrease the pain.

Several conventional treatments have been proven effective for treating CTS. Wrist splinting, helps relieve wrist pain by providing mild pressure and decreasing motion of the weak or injured wrist joint. It is particularly effective when worn at night where the wrist is kept in a neutral position preventing the wrist from bending towards the palm (1). Although nighttime use of splints may be more convenient, full-time use will maximize physiological benefits. A randomized study of 21 patients showed that when a physician advise certain patients for full-time wear the speed of distal nerve conduction improved more in those assigned to full-time use (2). Clinical studies have also shown a marked improvement in relief of symptoms over surgery when wearing a splint. Long-term clinical responses to splinting showed a shorter duration of symptoms and less severe nocturnal numbness (3). Any over-the-counter cockup wrist splint with a rigid insert will work. If discomfort occurs with the ready made splint, please visit an occupational therapist to have a custom made splint fabricated.

Ultrasound is another form of conventional therapy. Ultrasound employs high-frequency sound waves directed toward the inflamed area. The sound waves are converted into heat in the deep tissues of the hand, which opens the blood vessels and allows oxygen to be delivered to the injured tissue. It may be efficacious in the treatment of mild to moderate carpal tunnel syndrome. Studies have indicated that active ultrasound treatments resulted in significant improvement.

If symptoms subside, the patient may proceed with a physical therapy, a supervised program of joint mobilization and hand and wrist strengthening and stretching, usually offered by physical or occupational therapists. Hand and wrist exercises are a beneficial adjunctive treatment for patients with mild to moderate disease who are also treated with splints and other conservative measures.

Nonsteroidal anti-inflammatory drugs (NSAIDs) work to both relieve the pain and the swelling of arthritis sufferers. For CTS, these medictaions are best used to treat acute flare-ups. Long-term use of NSAIDs for treating CTS hasn't shown much success. These medications can be bought over the counter or at higher strengths by prescription. Long term use of NSAIDs may cause gastric complications such as bleeding ulcers, and liver or kidney damage. Again, drinking alcohol may exacerbate this effect. You should openly discuss all concerns regarding these medications with your doctor.

COX-2 inhibitors also help to control pain and relieve joint swelling without the risk of gastric malaise. COX-2 inhibitors however, are not without the risk of side effects. Prolonged use of these drugs may cause fluid retention, and high blood pressure. Recent studies link some COX-2 inhibitors to increased risk of heart attack.

Corticosteroid Injections may provide useful results in some patients. Corticosteroids (also called steroids) reduce inflammation. If restriction of activities and the use of painkillers are unsuccessful, the doctor may inject a corticosteroid into the carpal tunnel. Some experts recommend them for patients with CTS whose symptoms are intermittent and there is no evidence of a permanent injury. In CTS, steroid injections (such as cortisone or prednisolone) shrink the swollen tissues and relieve pressure on the nerve. Clinical studies showed in a trial of 81 patients, the patients injected with the Corticosteroid displayed highly satisfied results as compared to those who where injected with a sham-injection (4).

Unfortunately steroid injections may provide only short-term relief, long-term benefits are more variable. A study showed, after two to four months, 81 percent of the patients who where using Corticosteroid injections exhibited reoccurring pain. 46 percent encountered severe pain to warrant surgical treatment (5). Most physicians limit steroid injections to about three per year, since they can cause complications such as rupture of tendons, nerve irritation, or more widespread side effects such as hypertension or elevated blood sugar levels.

Early diagnosis and treatment are important to avoid permanent damage to the median nerve. A physical examination of the hands, arms, shoulders, and neck can help determine if the patient's complaints are related to daily activities or to an underlying disorder, and can rule out other painful conditions that mimic carpal tunnel syndrome. The wrist is examined for tenderness, swelling, warmth, and discoloration. Each finger should be tested for sensation, and the muscles at the base of the hand should be examined for strength and signs of atrophy. Routine laboratory tests and X-rays can reveal diabetes, arthritis, and fractures.

Physicians can use specific tests to try to produce the symptoms of carpal tunnel syndrome. In the Tinel test, the doctor taps on or presses on the median nerve in the patient's wrist. The test is positive when tingling in the fingers or a resultant shock-like sensation occurs. The Phalen, or wrist-flexion, test involves having the patient hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together. The presence of carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute. Doctors may also ask patients to try to make a movement that brings on symptoms.

Often it is necessary to confirm the diagnosis by use of electrodiagnostic tests. In a nerve conduction study, electrodes are placed on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured. In electromyography, a fine needle is inserted into a muscle; electrical activity viewed on a screen can determine the severity of damage to the median nerve. Ultrasound imaging can show impaired movement of the median nerve. Magnetic resonance imaging (MRI) can show the anatomy of the wrist but to date has not been especially useful in diagnosing carpal tunnel syndrome.

Treatment and Prevention
For carpal tunnel, acting quickly at the first hint of a symptom can often head off a full-blown irritation. The natural position of the working hand is with the wrist held straight or slightly bent and the thumb in a continuous line with the forearm. Using your hand with the wrist bent, either forward or back, places a stress on the nerves as they pass through the carpal tunnel. So to prevent CTS, your best bet is learning to work with your wrist and hand held straight. Adjust the height of your chairuntil you are positioned your wrists in a straight line. Find out if your business employs consultanats that specialize in creating ergonomically correct workstations. If you must perform repetitive movements, like those required by a keyboard, take a break every hour and exercise both your hands and your wrists.

Conventional treatment usually begins with recommendations for rest, cold compresses, and wrist splints. The splints are usually worn for two to three weeks--especially at night when you may bend your wrist in your sleep. At the workplace, a good wrist splint allows you to continue your usual hand-related tasks. However, you may just have to discontinue certain troublesome actions for a week or two in order to allow time for the swelling to go down. In severe cases of CTS, your work duties may need to be altered. If so, you should consult an occuptaional therapist. These doctors are experienced in helping adjust aspects of your daily routine to work with not against your condition.

Your doctor may recommend an anti-inflammatory medication, usually aspirin, an NSAID or one of the new COX-2 inhibitors. If you don't respond to this program, a course of intensive physical therapy, corticosteroid injections, or even surgery may be recommended.

Unfortunately, the ultimate conventional remedy, surgery, provides relief for troublesome symptoms in less than half of CTS patients. For this reason, WholeHealthMD physicians routinely recommend that surgery should only be pursued if there's clinical evidence of damage to the radial or ulnar nerve with unremitting pain, numbness, and possible actual wasting of the muscles of the affected hand.

And we also feel it's always a wise strategy to try a three- to six-month trial of noninvasive therapies before you think seriously about undergoing surgery. Conventional physicians are often unaware that a variety of alternative therapies have been shown to be quite helpful in treating CTS. These include osteopathic and chiropractic manipulation, acupuncture, massage, and magnet therapy.

Actually, you might consider one of the manipulative therapies, such as osteopathy or chiropractic, well before considering surgery. You've basically got a mechanical problem, i.e., a compressed nerve due to some local swelling. Gentle manipulation of the bones and soft tissue of the wrist by a health-care provider trained in the appropriate techniques may actually shift the fluids responsible for the swelling and release the entrapped nerve. Although such treatment may take several visits, you can really tell if you're heading in the right direction because your pain should lessen and your grip strength improve.

There are also a number of specific lifestyle changes you can make, as well as several supplements that can help improve your circulation, reduce the inflammation and generally promote healthy nerve tissue.

Just a reminder: If you have a serious medical condition or are taking medication, it's always a wise idea to talk to your doctor before beginning a supplement program.

How Supplements Can Help
Fish oil, containing the essential omega-3 fatty acids, eciosapentaenoic (EPA) and docosahexainoic acid (DHA) is an important component of any supplement regimen to heal CTS. While it has not been studied specifically in cases of carpal tunnel syndrome, many studies exist proving its efficacy in treating other inflammatory, pain and arthritic conditions. Look for a brand that is certified to be heavy metal free. Your daily dosage should contain at least 2500 mg total of EPA/ DHA.

Early research suggested that people who don't have enough vitamin B6 in their diet are more likely to feel the pain and numbness of carpal tunnel syndrome. More recent research, however, suggests that people with carpal tunnel syndrome do not benefit from treatment with vitamin B6 (5, 6).

You may benefit, however, from botanical anti-inflammatory nutrients like bromelain,ginger and turmeric. Bromelian, a natural anti-inflammatory enzyme found in pineapple stems, is often combined with other botanical or nutritional supplements. To enhance the benefits of bromelain, take the herb turmeric, which is a member of the ginger family. Its anti-inflammatory effects are due to its active ingredient, a substance called curcumin. Although it's safe to take over the long term, turmeric can be expensive, so you may want to cut the dosage in half once your symptoms subside. One efficient way of getting the pain relieving effects of turmeric, is to add it too your food. Cook with it at least five times a week. If you prefer capsules or tincture, then look for a form that has been standardized to 90 - 95% curcumin. Try 500 - 1000 mg a day in capsule form, or .5 - 1.5 ml tinture three times a day. Ginger, a relative of turmeric, also works as an anti-inflammatory, either in capsules, as a spice or as a tea.

Self-Care Remedies
During flare-ups, over-the-counter anti-inflammatory pain relievers, such as aspirin and ibuprofen, can help reduce pain and swelling.

When lying down, elevate your affected arm with pillows.

To reduce pain and inflammation, apply a flexible ice pack (or even a bag of frozen peas) to your wrist for 10 minutes every hour.

When working with your hands, try to keep your wrists straight. Flexing or twisting them stresses the carpal tunnel.

Try to vary activities and rotate tasks so that your wrists are not constantly bent.

Take frequent rest and stretching breaks during any activity that requires repetitive hand motions. At least once an hour, extend your wrist and fingers and shake your hands.

When working at a computer keyboard, make sure your fingers are lower than your wrists. Don't rest the heels of your hands on the keyboard or mouse pad.

While driving, avoid gripping the steering wheel too tightly.

To reduce stress on the wrist, lift objects with the entire hand, or better yet, with both hands.

Listen to your body. If your hands hurt during an activity, it's time to stop.

Reduce the amount of salt in your diet. Salt promotes water retention, which can contribute to swelling.

Quit smoking. Smoking aggravates the condition by constricting the small blood vessels of the hand.

Fingerless gloves, may help symptoms by keeping the wrist warm, or they may worsen symptoms by putting more pressure on the carpal tunnel. Ask your doctor if these implements are recommended for your particular condition.

If symptoms persist, your doctor may prescribe a wrist splint, diuretics to reduce water retention or injections of corticosteroids to reduce inflammation.

In cases of advanced nerve injury or muscle damage, surgery may be suggested.

Yoga practice may be specifically very helpful for carpal tunnel, since yoga postures are designed to stretch, strengthen, and balance upper body joints. In one study, people who practiced yoga for eight weeks experienced significantly reduced symptoms compared to wrist splints or no treatment at all. Two other small studies also reported improvement in pain relief (7). Some people anecdotally report that positive effects take a few weeks of regular practice of at least two sessions a week.

Some experts have reported that people who are physically fit, including athletes, joggers, and swimmers, have a lower risk for cumulative trauma disorders. Although there is no evidence that exercise can directly improve CTS, a regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back, helps reduce weight, and improves overall health and well-being. In one 2001 study, CTS patients experienced symptom relief and signs of improved nerve conduction after 10 months of participation in an aerobic exercise program. (Such improvements appeared to be due to both weight loss and higher oxygen levels.) One study found that most people with CTS felt improvement after two months of physical therapy that included exercises to improve balance and posture. People with any chronic medical condition or with risk factors for heart disease should check with their physicians about an appropriate regimen.

As noted earlier, acupuncture may be helpful for patients with CTS. In one study, 83% of the participants treated with acupuncture experienced complete relief that lasted through two to eight years of follow-up (8). After reviewing all available scientific literature on the topic, a consensus conference convened in 1997 by the National Institutes of Health concluded that acupuncture for CTS â€œmay be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.â€ (9)

The Evidence Based Rating Scale is a tool that helps consumers translate the findings of medical research studies with what our clinical advisors have found to be efficacious in their personal practice. This tool is meant to simplify which supplements and therapies demonstrate promise in the treatment of certain conditions. This scale does not take into account any possible interactions with any medication/ condition/ or therapy which you may be currently undertaking. It is therefore advisable to ask your doctor before starting any new treatment regimen.

To begin, it's pretty universally agreed that a rest from the culprit activity, wrist splints and anti-inflammatory medications can help relieve your CTS symptoms. In addition, physical therapy can really aid in rebuilding the strength and improving the motion in your hand and wrist.

But many people with CTS seem unable to get rid of all their symptoms even after a course of conventional treatment. Or instead, they may manage a few good weeks, only to have the problem resurface again and again. It's here that some nutritional supplements can help.

How to take the supplements

During the acute phase of this condition, take all the supplements in the doses recommended. Vitamin B6or pyridoxal-5-phosphate (P-5-P), a form of vitamin B6 that the body produces naturally helps maintain healthy nerve tissue, although the body of research suggests that vitamin B6 may have no significant effect on your symptoms. Bromelain acts as an anti-inflammatory, and either the turmeric or the ginger will enhance the bromelain's anti-inflammatory effect.

With no active inflammation, you can discontinue the bromelain and turmeric. When you are finally symptom-free, the amount of vitamin B in your high-potency multivitamin may be sufficient to keep CTS at bay.

Women, men, those over 50, those with chronic illness, and vegetarians have special needs to consider when choosing a multivitamin. Review your special needs below.

Why Everyone should be Taking a Multivitamin

There's nothing like a sound, low-fat diet full of fruits, vegetables, and whole grains to supply the vitamins and minerals we need to stay healthy. Unfortunately, we don't always eat well. Add to that the possible harmful effects of stress, aging, lack of exercise, pollution and illness, and supplements become even more important. That's why so many experts now recommend that everyone take a daily multivitamin.

The Right Choice: See Our Multivitamin Chart

This chart outlines the key vitamins and minerals your multivitamin should supply and the main benefits of each nutrient. It also gives what's called the daily value (DV) - a new government standard that generally corresponds to the RDA. The DV satisfies minimum daily requirements and helps prevent a deficiency disease, such as scurvy (lack of vitamin C). The higher levels of vitamins and minerals found in many multivitamins may actually help prevent disease, delay its onset or even lessen the severity of certain ailments.

Good Reason to Take an extra-strength Formula

If you eat an optimal diet of low-fat foods, at least five servings of fruits and vegetables daily, and chicken, lean meat, or fish several times a week, you can probably get away with a once-daily formula. But even those who consume a fairly well rounded diet and yield to junk-food lapses only occasionally can benefit from an extra-strength formula. If your idea of lunch is a slice of pizza and a diet soda, look for a multivitamin in the upper ranges of our chart.

•Read the label carefully to see
what you're getting. Many "high-potency"
formulas provide only extra amounts of the less-expensive ingredients.

•Don't pay more for "timed-
released" or "related" products. They're not worth the extra cost.

• Check the serving size. You may need to swallow up to six extra-strength pills a day to get the amounts listed on the label.

•Don't double up on one-a-days You'll be getting too much of certain nutrients, and not enough of others. If you want an extra-strength formula, buy one.

• Avoid mega doses that greatly exceed the upper doses listed in our chart, especially with fat-soluble vitamins A, D, E, and K; the minerals iron and selenium; or when taking any supplements long term. Be sure to account for any vitamins and minerals you may also be taking as individual supplements or as part of an herbal formula.

Fights infections; maintains eye and skin health. May be supplied in part as beta-carotene, which may lower the risk of cancer and heart disease and boost immunity. Pregnant women should not take more than 5,000 IU of vitamin A daily, but higher doses of beta-carotene are safe.

Promotes healthy bones and teeth; may protect against cancer.Adults may be deficient even with the usual doses of 400IU in multivitamins. Those over 50 should get at least 1000 IU and those over 70 may need at least 2000 IU of Vitamin D3. Avoid daily doses exceeding 10,000 IU, which may be toxic.

400 IU

200-400 IU

may need an additional 1000IU above what is in the multivitamin. Get a Vit D blood test to determine your needs.

Prevents anemia in younger women. Men and postmenopausal women should opt for iron-free formulas. Vegetarians who avoid all animal products and women with heavy periods should get at least 18 mg a day. Don't exceed 65 mg daily.

May cure colds, relieve prostrate complaints, and slow macular degeneration. Vegetarians who avoid all animal products, including dairy and eggs, should aim to get 30 mg. Don't exceed 60 mg daily, which can be harmful.

15 mg

15 mg

15-30 mg

Special Needs

Women

of all ages need at least 1,200 mg of calcium daily, through supplements or diet, to slow bone loss. Most multivitamins don't supply this much: A separate calcium supplement is probably your best bet. Younger women, especially those with heavy menstrual periods, need plenty of iron (18 mg a day ). Those considering pregnancy should get extra folic acid and avoid high-dose vitamin A. Special "women's formulas" may contain expensive herbs you may not need.

Men

should avoid multivitamins containing iron: Iron build-up has been linked to heart disease. Be wary of "men's formulas that tout ingredients like saw palmetto for prostate complaints. Many of these high-profile "extras" are present in such small amounts that they provide little or no therapeutic benefit.

Over 50,

opt for iron-free formulas: Too much of the mineral can cause heart problems. Look for vitamins B6 and B12 in the higher ranges, because as people age, they often have trouble absorbing these nutrients. Older women and men can benefit from the bone-strengthening effects of extra calcium (1,200 mg a day) and vitamin D (400 to 600 IU a day).

Chronic Illness

can lead to poor eating habits or deplete nutrient stores. Extra-strength formulas are especially important if you suffer from a long-term digestive ailment or have liver or gallbladder problems. Consult your doctor before taking supplements.

Vegetarians

who avoid all animal foods, including dairy and egg products, need at least 100 mcg daily of vitamin B12. Zinc, iron and calcium are also very important minerals for strict vegetarians.

Disclaimer: All material provided in the WholeHealthMD website is provided for educational purposes only. Consult your physician regarding the applicability of any information provided in the WholeHealthMD website to your symptoms or medical condition.